Presidential Candidates Peddling Unproven Reform

There is little evidence that "disease management" (DM) programs are effective in controlling health care costs, according to an article published in the May/June issue of Annals of Family Medicine which reviews recent studies of the programs. Yet all of the leading Democratic presidential candidates have made the programs -- which aim to reduce health care costs and/or improve care quality by helping patients manage chronic conditions such as diabetes and heart disease -- a plank of their health reform platforms, and a number of states (such as Vermont) have made DM a central component of state-level reform.

"Considering the scant evidence of cost savings from "disease management" programs, it is astounding that the candidates have rushed to embrace and promote them as panaceas," said Dr. John Geyman, Professor Emeritus of Family Medicine at the University of Washington and author of the article. "One is reminded of the similar rush to embrace managed care in the 1990s, which was also a dismal failure."

Dr. Geyman points out that much of the best data casts doubt on the ability of DM to control costs:

* A 2005 report by Dr. David Eddy and colleagues on the long-term effect of DM on diabetes costs concluded that "Even for the most optimistic picture...the net effect on diabetes-related costs would be an increase of about 25 percent."

* A 2006 analysis calculated that DM programs would need to decrease hospital admissions by 10 percent to 30 percent to cover program fees alone.

In the Annals article, Dr. Geyman identifies two types of DM programs. The first is nonprofit chronic care programs integrated with primary care. These programs can include evidence-based treatment guidelines, and on-site consultations with expert doctors and nurses, and electronic disease registries. Programs of this type have been found to achieve improved care quality, but in many cases raise costs.

The second type is rapidly-growing, for-profit DM programs which are carved-out and separate from primary care. This corporate model is marketed to employers and health plans as a way to cut costs. The development of commercial DM programs has been spearheaded by the pharmaceutical industry since the early 1990s. Such programs also produce profits for DM vendors and related industries (for instance, DM companies will call patients and suggest drugs they should ask their doctors to prescribe). These programs find it difficult to provide sustained improvement in quality of care because of their uncoordinated nature and disconnect from primary care. Studies of the impact of commercial DM programs, many of which are funded and conducted by industry, have been limited by short-term follow-up, focus on single chronic diseases without accounting for co-morbidity or program costs, and publication bias.

"Management of chronic disease is best accomplished by physicians and other health professionals working closely with patients in primary care settings," said Dr. Geyman. "Corporate disease management programs are contradictory to this relationship. How can a person in a distant commercial call center recommend the best diabetes drugs to a frail Medicare patient she has no relationship with, especially since such patients typically have several chronic diseases, not just one?"

Moreover, some physicians have reported adverse problems from corporate DM vendors, which sort through patients' insurance claims data looking for potential customers. Three patients of Dr. Deborah Richter, a family physician in Vermont, were contacted by DM firms and mistakenly told they had diseases they didn't have.

"These DM companies are so focused on making a profit that they will put anyone with a symptom on their list. Two of my patients received letters erroneously telling them they had chronic diseases, scaring the daylights out of them. Another was harassed on a weekly basis by a DM company "nurse" about a condition she didn't have. She was afraid to come see me because she thought I had sent this person."

Despite the lack of evidence as to DM programs' ability to control costs and problems associated with them, Hillary Clinton, John Edwards, and Barack Obama have all endorsed DM programs as part of their health reform plan. In addition, states such as Illinois, Pennsylvania and Vermont have all proposed taking up DM programs.

"'Disease management' is only the latest in a series of panaceas that have been offered as a way to avoid facing the real problems in our health system: private insurance companies," said Dr. Quentin Young, National Coordinator of Physicians for a National Health Program. "The only way to control health care costs is to evict wasteful private insurers and create a single-payer national health program which can streamline our patchwork payment system and rein in costs through rational budgeting. Until we have leaders that are willing to take on these big problems and the powerful interests that create them, there is little hope for solving our health care crisis."

Physicians for a National Health Program is an organization of 14,000 physicians that support single-payer national health insurance. PNHP is headquartered in Chicago and has chapters and spokespeople across the U.S. To contact a physician-spokesperson in your area, contact nick@pnhp.org or call 312-782-6006. www.pnhp.org.